Reconstruction After Trauma to the Brachial Plexus
RALPH LUSSKIN, M.D. JAMES B. CAMPBELL, M.D. ARTHUR BATTISTA, M.D.
The prognosis for successful reconstruction of the brachial plexus after trauma has been considered quite poor. Spontaneous recovery after stretch or contusion of the plexus has been well documented, and many authors have felt that surgical intervention would not improve the results.
Recent improvement in the technology of neural reconstruction seems to have altered the picture for some patients with laceration or other localized lesions of the plexus. In addition, there have been enough instances of better-than-expected recovery of function after neurolysis to suggest that some patients would benefit from such surgery. Nevertheless, attempts to alleviate the effects of stretch injury must be carefully evaluated against the background of the factors affecting prognosis and the feeling that surgery benefits only open injuries 2 .
The results in a series of cases at New York University Medical Center indicate that some open injuries of the plexus could be reconstructed by autografting, that some cases of stretch injury or contusion might benefit from neurolysis, and that an occasional patient might be helped by resection of neuromata-in-continuity and autografting 1 . In addition, we have been able to rehabilitate the proximal segments of the arm surgically by shoulder stabilization and pectoralis major transfer where irrevocable C5-6 lesions have been present.
This report presents the method used to identify patients expected to benefit from neurological surgery, discusses the surgical approach which offers the best opportunity and success, and reviews some of the results of reconstructive procedures.
Open wounds of the plexus produced by laceration have been explored as soon as the initial wound healed and acute reaction to the trauma subsided, usually three to six weeks. Closed wounds produced by clavicular fragments driven downwards can be explored as soon as the initial reaction to trauma subsides. When emergency vascular reconstruction is required, it is usually impossible to assemble the team to repair the plexus, but nerve ends should be tagged, not resected and discarded.
Stretch lesions of the plexus require evaluation over a period of time, not immediate surgery. Careful clinical examination must be performed immediately and repeated at frequent intervals. Six weeks after injury the state of the roots should be studied by myelography. Avulsion of roots may be demonstrated by meningeal sacks and by absent root shadows. A Homer's syndrome suggests a poor prognosis, as does the presence of sensory reflexes. Pain persisting after three to six months does not augur well.
Bioelectric studies are performed at six weeks, since these studies may provide important information not obtained by clinical examination. These tests should be repeated at three-to-six-month intervals. Should the progress of recovery slow or stop by clinical testing, exploration may be indicated. Descending paresthetic sensations and Tinel's sign may lead to a false hope of recovery, since these may be produced by only a few regenerating axons.
A rehabilitative program of constant exercising of the hand and elbow must be instituted. Profound thickening and contractures of the collateral ligaments of the metacarpo-phalangeal joints results from inadequate exercise. No reconstructive procedures will mobilize these joints. Electrical stimulation, massage, and such modalities as ultrasound do not positively affect the joints, muscles, or nerves.
Surgical reconstruction of the plexus by direct suture will rarely be possible. The only technique which offers a reasonable chance for recovery requires resection of neuromata and damaged nerve ends and the bridging of the resultant gap by small-diameter cable nerve autografts. Silicone sheeting of the anastomoses is no longer used, since magnification now permits meticulous suture technique. Inter-fascicular grafting, when possible, is useful to align perineurial tubes above to perineurial tubes distally.
Prior to surgery the patient should be studied by angiography if there has been a previous vascular injury or significant skeletal fragmentation involving the first rib or proximal humerus. A vascular team should be available when surgery is performed, in any event.
Long, tedious surgical procedures are best performed by orthopedic and neurosurgical teams working together and sequentially. Extra assistance is required to prepare and drape both legs as well as the involved arm, pectoral region, neck, and shoulder. A transclavicular approach is used in most instances.
The draping and skin incisions are demonstrated in Figure 1-A. The incision starts in the posterior triangle just behind the sternomastoid, crosses the midportion of the clavicle, and then aims for the axillary crease. If necessary, it can be extended along the medial brachium. The thorax may be opened by incision into the sternum and laterally below the second rib.
Figure 1-B. shows the dissection to the omohyoid above, and the development of the deltopectoral interval below, after excision of the cephalic vein.
Finally the plexus is explored within the axillary sheath after transection of the clavicle, the subclavian muscle, and the pectoralis minor insertion. The pectoralis major is divided if necessary (Fig. 1-C). The subclavian and axillary arteries and veins may be intimately bound to the plexus, requiring a most careful dissection. Once a lesion amenable to repair is identified, the site is prepared by cutting back the nerves until fascicles can be identified proximally, and appropriate distal recipient nerves are prepared. Sural and saphenous nerves are removed and kept buried in the wounds until the appropriate segments are cut for grafting. The donor nerves must not dry out. One suture at each end of a graft fixes it. An operating microscope facilitates the repair.
The following cases demonstrate positive results following reconstruction and neurolysis.
C.R. was a 9-year-old boy who sustained a laceration of the plexus by glass (Figure 1-C. ). An arterial repair has been performed. The angiogram demonstrated a functioning repair with slight narrowing and no aneurysm. The approach to the plexus is shown in Figure 2-A. . The clavicle is divided, and the sheath is demonstrated. All cords were found to be divided. The neuromata have been resected. Autografts were then completed (Figure 2-B. ), and finally the clavicle was repaired with a Steinman pin. Figure 2-C. demonstrates function two and one-half years after surgery.
N.G. was a 29-year-old nurse who sustained a surgical lesion of the upper trunk during a scalene myotomy (Figure 3-A. ). Repair of the lesion is demonstrated in Figure 3-B. . Fifteen months post repair, good deltoid and fair biceps function could be demonstrated (Figure 3-C. and Figure 3-D. ).
R.Y. illustrates neurolysis after blunt trauma (Figure 4-A. ). The patient was 50 years of age and had rather extensive residuals from poliomyelitis. An upper-plexus lesion followed a blow to the shoulder during an automobile accident, with no recovery after six months. Exploration revealed extensive cicatrix beneath the clavicle (Figure 4-B. ). Neurolysis was followed by increased electrical response and a return to preinjury strength in three months (Figure 4-C. ).
We have previously reported the results of a series of 20 explorations of the plexus, most with neurolysis 1 . This report adds two additional autografted cases to the two in that series. All four cases treated by autografting developed useful function in the segments which were repaired. This type of reconstruction should be undertaken when a lesion is present distal enough to permit a proximal anastomosiS.
There are enough documented cases of rapid improvement after neurolysis to justify this operation in selected patients. Our series of 1 7 patients treated by neurolysis resulted in 1 3 instances of return of function in at least one joint, and in improved sensation. Of the five patients operated upon under one year post injury, there was immediate or almost immediate (three-month) improvement. These patients had stationary or worsening lesions prior to surgery.
The worst cases are complete lesions produced by stretching secondary to a blow or fall on the shoulder. Motorcycle injuries produce the bulk of these lesions. The irrevocable lesions are often identifiable by myelography. Pain persisting for more than six months gives a bad prognosis. Peripheral approaches have not been uniformly successful in controlling pain, but fascicular ligation now offers some promise.
A discussion of the neurological reconstruction of the plexus would not be complete without a report of the orthopedic procedures performed. In a total of 26 patients, we performed two claviculectomies for sepsis, two osteosyntheses of the clavicle (one for failed repair after exploration and one following segmental resection during arterial repair), five arthrodeses of the shoulder (one with a brachial amputation), and three amputations the high brachial amputation being satisfactory when no pectoralis or shoulder extensors were functioning. Four successful pectoralis major transfers have been performed following shoulder fusion, although one required secondary plication of the distal insertion.
- Lusskin, R., J. B. Campbell, and W. A. L. Thompson, Post traumatic lesions of the Brachial Plexus, treatment by transclavicular exploration and neurolysis or autograft reconstruction. J Bone Joint Surg, 55A:1 159, 1973.
- Sunderland, S., Nerves and Nerve Injuries, p. 887. Churchill Livingston, Edinburgh, 1978.